Treatment Consent

Please read this entire document carefully before agreeing.

Welcome to Skycloud Mental Health: This agreement provides those who seek treatment from Skycloud Mental Health with a clear understanding of how we manage our office. This document is intended to provide you with enough information to make an informed consent to participate in treatment. Please read it carefully and do not hesitate to discuss your questions or concerns about this information with Skycloud Mental Health.

Assessment:

Your provider will gather historical information to help them learn about your situation and determine what treatment intervention will be best for you. If your provider determines that Skycloud Mental Health cannot offer you the services you need after your initial assessment, you may receive a referral to a provider who can offer you appropriate treatment as determined by your initial assessment.

Treatment:

Once it has been established that Skycloud Mental Health is an appropriate resource for you, you and your provider will develop a plan of care to guide your recovery. In order for the plan of care to be successful, you must actively be engaged in your care by informing your provider of any disagreements or issues related to your care then following the agreed-upon recommendations such as medication regimens and attending appointments as scheduled. You will be offered services specifically designed for you. These may include medication management with Skycloud Mental Health or therapy.

Appointments:

If you arrive late to your appointment, you may be asked to reschedule your appointment. Missed appointments, late cancellations, or failure to follow appointment recommendations may lead to your dismissal as a client of Skycloud Mental Health at the discretion of your provider. Missed appointments and cancellations with less than 24 hours notice will be charged the full self-pay rate of the appointment.

Telephone Calls:

Skycloud Mental Health has a 24-hour answering system (503-694-3381), you may leave messages at any time. Messages may not be returned for 1-2 business days. If you are in a crisis situation, please do not leave a message. Go to the closest emergency room for treatment, call 911, call the National Suicide Hotline at 988, or text CONNECT to 741741.

Controlled Substances:

Skycloud Mental Health has a strict policy regarding controlled substances. Examples of controlled substances are Vyvanse, Adderall, Concerta, Ritalin, Klonopin, Ativan, Xanax, and Valium. We may prescribe stimulant medication for the treatment of ADHD when diagnosed to individuals in Oregon and Washington. We do not prescribe any other controlled substance medications, such as benzodiazepine medications, Suboxone, or methadone. We do not prescribe stimulant medications in any other state. We require an an-office visit once per year for controlled substance medications. In-office visits are available in Beaverton, Oregon and occasionally in Seattle, Washington. Not all of our providers are able to prescribe controlled substance medications within our practice. A thorough evaluation is required prior to the prescription of a controlled substance for the treatment of ADHD and a prescription should not be expected at the first visit. Signing our controlled substance agreement is also required. Other requirements include a baseline Urine Drug Screen, random Urine Drug Screens, an EKG when clinically necessary, and obtaining a home blood pressure cuff. The Prescription Drug Monitoring Program is reviewed. If you are recently prescribed a stimulant and wishing to continue treatment, you must sign the release of information form for your current provider so we may obtain records. After May 11, 2023, no controlled substance medication may be initiated without an in-office visit, per federal law. Contact our practice with questions.

Medication Refills:

Medication refills are only provided to existing patients and refill requests should be made at least one week in advance. If you have not yet had a psychiatric evaluation at Skycloud Mental Health, you should contact your most recent prescriber for refills. Medication refills outside of appointments are determined on an individual basis. You may be required to have an appointment prior to receiving a refill or may only receive enough medication to get you to your next scheduled appointment. Please allow for at least 5 business days to receive a response regarding medication refills. Medication refill requests should be made by calling/texting 503-694-3381 or using the messaging system in your patient portal. Please include the patient’s first and last name, the patient’s date of birth, the relation of the person requesting a refill if not the patient, preferred pharmacy name/phone number, name of the medications being requested, and date of the patient’s next scheduled appointment.

Termination:

Termination is inevitable. It should not be done casually. Skycloud Mental Health providers can terminate your treatment at any time for non-adherence to your plan of care. Either you or your provider can terminate your treatment.

Complaints:

If you are dissatisfied with any aspect of your treatment, please discuss it with your provider. You may also voice complaints by calling 503-694-3381. Skycloud Mental Health respectfully requests that we be given the opportunity to address your complaints before you post a complaint publicly.

Emergencies:

We may use or disclose your health information to notify or assist in the notification of a family member or anyone responsible for your care, in case of emergency involving your care, your location, your general condition, or death. If at all possible, we will provide you with an opportunity to object to this use of disclosure. Under emergency conditions or if you are incapacitated, we will use our professional judgment to make reasonable inference of your best interest by allowing someone to pick up a prescription, or other similar forms of health information and/or supplies unless you have advised otherwise.

Appointment Reminders:

We may use and disclose health information to contact you as a reminder that you have an appointment for treatment at our office by call, text, or e-mail. If you do not wish to be contacted by these methods, please inform the clinic.

Alternative Treatment:

We may use and disclose health information to inform you about treatment alternatives and other health related benefits that we believe may be of interest to you.

Election to Self-Pay:

If you have a health insurance provider in network with Skycloud Mental Health but would prefer to self-pay for services, you can do so by agreeing with a form to indicate this. Any services provided prior to the form being agree to billed to your insurance. You can revoke this at any time by agreeing with a separate revocation form. These forms can be obtained by asking your provider or office staff. Any medical services provided from the time of agreement, the election to self-pay form until the date of agreement, the revocation form will not be billed to your insurance and you will be expected to pay as a self-pay client. Any medical services provided after the date of the agreeing, the revocation form will be billed to your insurance. Self-pay clients may be offered a discounted rate. You can inquire about self-pay rates by asking your provider or asking office staff. THIS DOES NOT APPLY TO INDIVIDUALS WITH MEDICARE. Skycloud Mental Health is not able to provide services to individuals with Medicare, cannot bill Medicare for services, and cannot accept individuals with Medicare as self-pay patients.

Legal Proceedings:

Skycloud Mental Health does not participate in court/legal proceedings. Evaluations provided by Skycloud Mental Health are for the purpose of diagnosis and treatment. Testimony in court, at depositions, administrative hearings, board reviews, and all time necessary for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority, will be charged at a rate of $750 per hour.

Telehealth Policies:

Skycloud Mental Health offers video appointments through www.skycloudhealth.com to individuals in the states in which the health care provider is licensed (updated on website). Patients must be located in one of these states at the time of the appointment but otherwise may be at any private location of their choice for the appointment. Video appointments require access to a device with audio and video capabilities as well as internet connection. Insurances may not cover video appointments. Pricing is posted on www.skycloudhealth.com.

Sessions and visits will be held via “telehealth”: using video conferencing software with audio capability and/or a separate software/device for audio (e.g, telephone, headset, etc.). Of note, telehealth establishes a formal provider-patient relationship used to maintain regular assessment, diagnostics, therapy, and/or prescription. We will be utilizing Health Insurance Portability and Accountability Act (HIPAA) protected software to ensure that your protected health information is secure from unauthorized access and that confidentiality is maintained. This document serves as a consent form for treatment via telehealth in general.

Benefits of Telehealth

Telehealth stands at the crossroads of cutting-edge technology and formal health services.You can expect the following benefits:

1. Telehealth eliminates barriers to accessing healthcare and provides an alternative means to obtain behavioral health services for patients who may otherwise have limited accessibility or encounter prolonged waiting lists in the community.
2. In addition to removing the burden of travel time to a physical medical office as well as the risks and costs associated with transportation, telehealth allows for flexible scheduling.
3. Telehealth offers a reduction of stigma by providing private treatment in the comfort of the patient’s personal space.
4. Telehealth can provide treatment to patients with disabilities and limited mobility without requiring extensive planning for transport.

Limitations of Telehealth

While it is not possible to anticipate all the limitations of any treatment, you should consider the following when consenting to treatment via telehealth:

5. Telehealth audio visual equipment may experience technical difficulties.
6. While every precaution is taken to secure patient data and maintain confidentiality, the nature of electronic appointments results in additional exposure to security breaches.
7. Telehealth may not be suitable for certain illnesses that require higher levels of care.
8. Certain illnesses may not be adequately treated by telehealth.
9. We reserve the right to assess suitability and appropriateness of telehealth candidates due to the potential limitations of the treatment modality mentioned above.

As telehealth is generally conducted remotely, safety protocols and alternate means of seeking help will be addressed in detail in your consultation. However, the following are generally accepted alternatives to treatment via telehealth: Treatment in a more traditional, in-office visit with another provider.

Pursuing treatment via telehealth is a decision made by you. If you choose to revoke your decision and pursue alternate treatment, you are able to withdraw your consent at any time. (Of course, we recommend discussing this decision with your provider first. We also recommend establishing your next provider prior to termination to eliminate any gaps in treatment). By signing this form I certify that I:

10. I understand that I am consenting to evaluation and treatment via telehealth.
11. I understand that no results can be guaranteed, despite our best efforts to deliver care.
12. I have been given the opportunity to ask questions about telehealth or any aspects of the evaluation and treatment at any time.

Confidentiality and Patient Rights:

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and respective ethical codes of the practitioners in this office. It also describes your rights regarding how you may gain access to and control you PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. You may request a copy of the Notice of Privacy Practices at any time.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purpose of collection. For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities.

For example, we may share your PHI with third parties that preform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of Privacy Rule. Without Authorization.

Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations {such as a licensing board or the health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. Verbal Permission We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to Skycloud Mental Health at 818 SW 3rd Ave #221-5258, Portland, OR, 97204

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosure. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice.

You have the right to a copy of this notice. Complaints If you believe we have violated your privacy rights, you have the right to file a complaint in writing to Skycloud Mental Health at 818 SW 3rd Ave #221-5258, Portland, Oregon 97204 or by calling 503-694-3381. Additionally, you may issue a complaint with the Secretary of Health and Human Services at 200 Independence Avenue. S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

Client Rights

• I have the right to receive information about my managed care companies’ services and treatment providers, clinical guidelines, and client’s rights and responsibilities.
• I have the right to be treated with respect and dignity.
• I have the right to privacy and confidentiality.
• I have the right to fair treatment. This is regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
• I have the right to the rights and privileges granted by State and Federal Law.
• I have the right to participate with my treatment provider in decision-making regarding treatment planning.
• I have the right to voice a complaint or appeal should a dispute arise over treatment or claims.
• I have the right to make recommendations regarding client rights and responsibilities policies that may be implemented.
• I have the right to a candid discussion of appropriate or medically necessary treatment options for my condition(s), regardless of cost or benefit coverage.

 

Client Responsibilities

• I have the responsibility to provide, to the extent possible, information that my provider(s) need in order to care for me.
• I have the responsibility to follow the plans and instructions for care that I have agreed upon with my treatment provider.
• I have the responsibility to participate, to the degree possible, in understanding my behavioral health problem(s) and developing mutually agreed-upon treatment goals.
• I have the responsibility to inform my provider of changes in my address and insurance coverage.
• I have the responsibility to keep scheduled appointments and comply with my treatment provider’s cancellation policy.

 

 

By accepting, you acknowledge: I have read the forms and have had the opportunity to ask any questions I may have had about the forms. Any questions I may have had about this form have been answered to my satisfaction.